Working across Hastings and Rother CCG and Eastbourne, Hailsham and Seaford CCG, the team sought to improve quality and efficiency of prescribing for neuropathic pain, whilst reducing variation in prescribing behaviour between GP practices across the CCG's.
The NICE guideline for the pharmacological management of neuropathic pain in the non-specialist setting (CG173) was issued in November 2013. NICE recommends offering a choice of amitriptyline, duloxetine, gabapentin or pregabalin as initial treatment for neuropathic pain. There are no head to head trials of these agents in neuropathic pain; all of the recommended agents have been shown to consistently reduce pain compared to placebo.
Our project set out to support implementation of this guideline locally.
Please note that in September 2020, NICE updated some aspects of CG173. Updates are detailed here. This example has been reviewed and practice described continues to align to the updated guidance.
Aims and objectives
- To improve quality and efficiency of prescribing for neuropathic pain
- To identify drivers for outlying position in both CCGs with regard to pregabalin prescribing
- To reduce variation in prescribing between GP practices
- To demonstrate implementation of NICE guidance locally
- To develop a strategy to reduce growth in high levels of default prescribing of pregabalin as part of a wider initiative to promote the full range of prescribing options, as recommended in the NICE guidance (Recommendation 1.1.8)
- To implement patient centred structured pain management reviews in primary care
Reasons for implementing your project
In a 12 month period (Jan-Dec 2013) NHS Eastbourne, Hailsham and Seaford and NHS Hastings and Rother Clinical Commissioning Groups spent approximately £1.6 million on pregabalin (prescribing for all indications). The average cost was £56.63 per prescription. Our CCGs has a combined population of 363,000 patients.
Spend on pregabalin prescribing in NHS Eastbourne, Hailsham and Seaford and NHS Hastings and Rother Clinical Commissioning Groups is much higher than expected based on national prescribing patterns. If prescribing of pregabalin was reduced to national levels, an additional £1million would be available to the local health economy. Locally there is significant variation in prescribing between practices
Through the national forecasting tool our team identified that there was a cost opportunity to be realised by looking at this therapeutic area. However this project has focused on improving the quality of prescribing and review of neuropathic pain medication. It has been through implementation of patient centred structured pain management reviews that we have realised cost efficiencies. Quality prescribing often costs less. All locally available pain services were mapped using support from Public Health, East Sussex County Council. The model of care provided by each service was identified and the views of clinicians working within each setting were sought. Any currently available care or referral pathways were identified, along with national or local clinical guidelines for pain management (focus on neuropathic pain in particular).
A clinical review of pregabalin prescribing in primary care was undertaken across East Sussex CCGs. GP practices were asked to identify any patient prescribed pregabalin in the previous 6 months. GP practices were asked to identify a sample of approximately 25% of patients prescribed pregabalin for any other indication for review using a standard data collection template. The review was focused on the following areas: Indication for use, clinical setting for initiation, proportion of first line use & frequency of pain management review.
The results showed that there is a relatively high proportion of pregabalin being prescribed for unlicensed indications. This highlights the complexity and difficulty of managing chronic pain, which may become refractory to standard treatments. A large proportion of the patients prescribed pregabalin were prescribed less than the median effective dose, highlighting an issue around effective dose titration of medicines for neuropathic pain and highlighting group of patients who may benefit from review.
Most prescribing of pregabalin is initiated in primary care, suggesting that the prescribing pattern is mainly driven by GP behaviour. A significant proportion of patients prescribed pregabalin had not tried any alternative treatments for neuropathic pain, highlighting a lack of awareness of the evidence base and current national guidance within primary care.
How did you implement the project
The team had a general implementation plan which involved firstly, meeting, influencing and negotiating with local pain management specialists. Working more closely with GPs and building relationships formed the basis of our ‘offer’ to them for their input and involvement in the project.
Whilst they were high prescribers of pregabalin they did not hold any strong belief that this was a superior product and were keen to support a more individualised approach to initiation of neuropathic pain medication by prescribers (as advocated by NICE). We developed an initiation guide for prescribers which identified the groups of patients who may be most suitable for each pharmacological agent (Prescriber decision aid) – this became embedded in our formulary following ratification at Area Prescribing Committee. Prescribing Lead GPs for the CCGs were also engaged at an early stage of the project. Hospital pharmacy colleagues were asked to provide support by raising awareness of formulary with doctors prescribing pregabalin in the Trust (non-pain specialities).
Education was delivered on the principles of neuropathic pain management and principles of the NICE guideline – focus on review (led by pain management specialists) was delivered to GPs as CCG GP education event (half day closure) – high attendance from GPs. We developed tools and resources to support review and withdrawal from medication (aide memoire documents, electronic templates on clinical systems that generated 2 week reducing dose prescriptions). A patient information leaflet was developed and training delivered for community pharmacists (as by pain specialists) to ensure consistent messages between health care professionals. Engagement with Local Pharmaceutical Committee to help share best practice messages with community pharmacy colleagues.
We reinforced key messages with clinicians (primary and secondary care) throughout year and provided training for hospital pharmacy staff to raise awareness of the project and gain support (e.g. adding communication to discharge summaries regarding need for review if neuropathic pain medicines started as inpatient for example following surgery). Regular updates were provided via GP locality meetings.
Meetings were held with every GP practice in the CCG to discuss patient centred pain management reviews as part of their incentivised Prescribing Support Scheme. The team were also responsive to feedback from GPs about suggested review process, and made this more flexible to suit individual patients/GP practices e.g. telephone consultation, practice pharmacist reviews. GPs were asked to review 4/1000 patient list size prescribed pregabalin to receive payment. Payment was received for undertaking patient centred pain reviews and was not linked to the outcome of the review. This initiative was sold to clinicians as a quality improvement project, not a medication switch programme to generate financial efficiencies. We found that this was key to engagement of clinicians and our success.
The majority of GP practices in each CCG undertook primary care reviews (82% overall). Each practice was set a target number of reviews based on list size (between 6-71 reviews).
The rates of withdrawal from pregabalin treatment were higher than expected, ranging from 12% to 64% between GP practices. A reduction in volume of prescribing has begun to emerge in both CCGs.
Please see the supporting material for a graphic of these results.
So far, estimated annual savings from this project are approximately £395K across both CCGs (based on reported number of patients withdrawn from pregabalin). These savings exceeded our expectations. The MM team had hoped for 10-25% reduction in pregabalin prescribing costs per GP practices, and most GP practices exceeded that aspirational target.
The team monitored the uptake of reviews within GP practices by searching on the allocated read code for review. Information regarding the outcomes from review were recorded on a data collection form. Information from these forms were analysed by the Medicines Management team. Numbers of patients withdrawn from pregabalin were recorded and annualised savings extrapolated.
The volume of prescribing of pregabalin was monitored using epact.net and communicated to GPs via our quarterly produced prescribing dashboard.
A patient evaluation exercise is currently being undertaken. However informal anecdotal reports from patients via GPs have provided quotes such as ‘I had no idea how much harm this medication was causing me’. GPs were also surprised at how many patients were happy to commit to trial withdrawal of medication as a strategy to assess ongoing benefit and side effect balance.
Primary care pain management reviews can be undertaken successfully by GPs. Patients with chronic pain are accepting of withdrawal of medication as a strategy for assessing ongoing benefit and side effects of treatment. Many patients are able to withdraw from treatment without adverse events. This supports the need for prescribing medication for neuropathic pain as a therapeutic trial and undertaking regular review as recommended in national guidelines.
Key learning points
It was critical to engage all key opinion leaders in the project. Our team focused mainly on engaging the chronic pain team in secondary care and primary care colleagues which was successful, but pregabalin prescribing in other specialities in secondary care continue to be a challenge e.g. neurology, rheumatology and post-surgical use.
The Medicines Management (MM) team spent a lot of time developing resources for GPs to use to make life easier (such as aide memoire and dose reduction schedules) however feedback from GPs at the end of the project was that each GP took an individual approach with each patient and therefore these tools had limited use. Our learning from this is to consult more widely on the need for such documents before investing resource in development.
MM advisers acting as a facilitator for the project helped maintain momentum and increased GP engagement. Some practice were overwhelmed by the idea of starting the reviews, and felt patients would not like the reviews. The team were able to support individual GPs by sharing ideas and experience from other GP practices to motivate. GP practices were encouraged to ‘start small’ and then scale up. The team recommended that GPs review ‘easier patient cohorts to increase their confidence in the review process. We also found that:
- Regular feedback on projects – to keep awareness high – is useful for all stakeholders.
- Financial incentive helped move this project up the priority list for some GP practices.
- Ensure everyone has a consistent message. Don’t assume everyone ‘gets it’. A few colleagues tried to influence consultants with email messages such as ‘Please don’t prescribe this, it’s very expensive’ which was very damaging to our quality-focused project reputation. Sometimes it really is easier to sell it yourself (if that’s what you are good at!).
- Be flexible, and listen to feedback from the people doing the work. Alongside resistance, there are usually some good ideas (for example ceasing to insist on face to face review – our view was changed after a GP explained how asking his patient with chronic pain in to see him, thereby causing him pain, was perhaps not the best way to start a conversation about analgesic reduction…
We have shared our experience with the NICE Medicines Prescribing Associates at a face-to-face learning day. As a result of this, there has been further adoption of medicines optimisation projects of this nature, throughout the country, that we have inspired, through sharing our experience.